TARGET 8: 'Flawed' death investigation highlights problematic coroner system

8 months 1 week 5 days ago Tuesday, February 06 2018 Feb 6, 2018 Tuesday, February 06, 2018 4:00:00 PM CST February 06, 2018 in Target 8
By: Jamie Grey, KOMU 8 Chief Investigator
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FAYETTE – Multiple coroners around the state of Missouri say their system is flawed, that elected citizen coroners are acting with little or no training, making sometimes irreversible decisions that could pose hazards to the community and pain for families. They say some cases are being mishandled, and there are likely too few autopsies being ordered.

Now, those coroners and their professional association are asking for a change. They want better and more training and standards set in place to update laws that, in many cases, haven’t seen a governor’s signature since the 1940s.
 
‘I never questioned anything until three years later’
 
Jay Minor was asleep in the bunk of his semitruck when his phone rang. It was July 21, 2011, and he was driving his rig across the country, taking his evening stop in Columbus, Ohio. On the other end of the phone was the girlfriend of his son, 27-year-old Jayke Minor. She broke the news. His son was dead.
 
“A police officer got on the telephone, and he said that my son had passed away. And honestly from that point, I can’t tell you any more of the conversation because I was frantic,” Minor said.
 
Jayke’s girlfriend told Fayette police he’d been sick for three days, acting confused the day he died. She said she’d left the mobile home around 4:30 in the afternoon on July 21. When she returned about an hour later, Jayke was in his bed, not breathing. Police said he was dead when they arrived; his skin was already cold. Officers decided CPR wouldn’t make a difference. Jayke had been dead too long.
 
Minor said Jayke had a history of drug problems, a history local police in Fayette knew about all too well. That history drove a critical decision by Howard County Coroner Frank Flaspohler: He ruled Jayke died from accidental drug overdose.
 
Jay Minor was disappointed, but he also accepted the news. It seemed possible, probable even.
 
“I didn’t question anything because I just figured he did his job, and that’s what happened,” Minor said.
 
But then came questions about a string of nonexistent records, a lack of drug test results and odd interactions with the county. Minor started to doubt the ruling.
 
“The more things that started to come about, the less I believed that. And, of course, when we got the toxicology report back, it started falling apart,” Minor said.
 
It was in 2013 that things really began to spin for Minor; the idea Jayke died from an accidental overdose of drugs was slipping.
 
‘For the job that the coroner did to make me believe for two years that my son did die of a drug overdose, and then to find out that he didn’t’
 
Minor said Flaspohler initially told him there was a delay at the state lab, then that the samples of his son’s blood were lost by the lab. Then Flaspohler said he hand-carried another blood sample to the lab.
 
In 2013, the Missouri State Highway Patrol Lab finally returned a report. Jayke did have drugs in his system – but not drugs coroners commonly believe could cause death. The only positive result: THC – the metabolite of marijuana. 
 
“You don’t die from marijuana,” Minor said. “So for two years, we thought he died of an accidental overdose. Now it comes back and says there’s no drugs involved.”
 
More than a year after that toxicology report, Flaspohler filed to correct the death record in 2014. Jayke, he determined, died of natural causes and cardiac dysrhythmia.
 
“The death certificate was changed, with no evidence to go by, to cardiac dysrhythmia, which basically means his heart stopped. But I don’t know why it stopped,” Minor said.
 
There was no autopsy. Jayke was cremated. The blood that went to the lab was destroyed as part of the usual protocol. The evidence was gone, but the questions kept growing.
 
‘Nothing proves anything of what happened or what might have happened’
 
While the toxicology results took a long time, it was even longer before Minor got a copy of a coroner’s report. It took intervention by another coroner, Pettis County Coroner Skip Smith. A chance meeting at a hospital brought Minor to Smith, and Smith said he’d help get some records.
 
In March 2016, Smith began his search, asking Flaspohler for the records. He ultimately sent two formal letters asking Flaspohler for the papers. He said Flaspohler finally agreed to meet months later at the gates of the Missouri State Fair in Sedalia.

Smith got the report, and it took only seconds to see the first problem: There was another deceased man’s name on the top of the report. That man’s name was scratched out, replaced with a hand-written “Jaykeb Minor.” Smith took that report to Minor, who was horrified and hurt.
 
“It’s way beyond a cut-and-paste error. I mean, it’s so unprofessional that he could have overlooked that,” Minor said. “It was so short and unexplanatory. There’s not much to it, really, when you start off with the wrong name on it. Then I notice there’s no date anywhere on the report.”
 
The coroner’s report: Discrepancies and errors
 
Minor turned over all of his records to KOMU 8 News for investigation. Immediately, it was clear there were obvious issues with the coroner’s report. The name was wrong. There was no date of death clearly indicated. While the police report stated Jayke Minor was in a bedroom when he died, Flaspohler stated his body was in the living room. While the police report stated Jayke Minor was cold when officers arrived, Flaspohler stated he found the body warm, even though he arrived after emergency responders.
 
“It just leaves you not knowing what happened. I mean there’s no way to tell what really happened,” Minor said.
 
Saline County Coroner Willie Harlow agrees there are no answers for Jay Minor about his son. Harlow and Minor first met in June 2017 when Minor took his frustrations to the Missouri Coroners’ and Medical Examiners’ Association Board, on which Harlow holds a seat.
 
“From the very get go, this case was flawed,” Harlow said. “You had EMS personnel, police personnel, and a coroner who all had three different reports as to where the body was and how the body was positioned; whether or not the body was cool or warm.”
 
Harlow does not mince words on this case; he directly blames Flaspohler.
 
“He killed the voice of Jayke Minor because he did not investigate, he did not do his job. And this family will never have closure,” Harlow said. “He made a quick decision that he was a drug user, so he died of a drug overdose. And at that moment in time, Frank Flaspohler was done with that case.”
 
Harlow: ‘We will never know the truth as to why Jayke Minor died’
 
Harlow said he believes Flaspohler absolutely should have ordered an autopsy on Jayke. His age alone was enough in Harlow’s book.
 
“Twenty-seven-year-olds do not just die for no reason. I mean, there has to be a reason they die. And the only way to determine that, unless there is a visible sign of a cause of death or manner of death, you have to do an autopsy,” Harlow said. “An autopsy reveals so much about what is actually going on inside of a person that you can’t see with the naked eye. But that was not done in this case.”
 
As for Jayke’s history of drug use, Harlow said that’s not enough to make a decision on a cause and manner of death, especially since the police report stated officers “were unable to find any evidence of drug use.” Again, Harlow said this was a case where an autopsy should have been ordered and referenced for a determination.
 
“He didn’t have toxicology. He didn’t have a needle sticking out of Jayke’s arm. He didn’t have drugs in the house. But yet he says he died of a drug overdose. That, in and of itself, is enough to tell someone there that this is someone who did not do their job,” Harlow said.
 
‘Whose blood was that?’
 
Once the toxicology results of the blood sample came back from MSHP’s lab, Minor said he was immediately suspicious. Harlow had the same feeling.
 
“So, he sent in blood that was at least two years old, unpreserved. And there’s very little evidentiary value to blood that is that old. And then the question comes into play: Was it really Jayke’s blood?” Harlow said.
 
Since the blood was destroyed, Harlow said, there is no way to know for certain if it was Jayke’s blood hand-carried to the lab. Workers there didn’t type the blood, so there’s no way to even find out if it’s possibly Jayke’s or someone else’s.
 
“You know, Jayke, as his parents have said, had used drugs but was never known to use marijuana, and then all of the sudden, you have this toxicology report come back that there is THC in the blood. It leaves the mind to wonder, whose blood was that?” Harlow said
 
‘I think it’s an accurate tox report’
 
Flaspohler met with KOMU 8 News outside the courthouse last week to discuss the blood sample, the coroner’s report and the lack of autopsy in Jayke’s death. He said the case took too long, but he is confident in his investigation and his findings.
 
While he doesn’t normally save blood samples for years, Flaspohler said, he did in this case:

“I really don’t know why I had some left over,” he said. “I don’t remember other than if there was too much in the syringe, and so I put a little more in the other one.”
 
Flaspohler said he is “100 percent sure” the blood he brought to MSHP was Jayke’s blood – and he said it was preserved. When asked if the blood could have degraded or lost some other toxins, he said no. He is confident THC was the only drug product in Jayke’s system, but he now says he believes that’s what killed him. That raised another question.
 
KOMU 8 News: “Why does it say natural rather than drug overdose if you believe THC was the cause?”
 
“Basically because cardiac arrhythmia is a natural cause. And I actually talked to the highway patrol lab about the THC, and I said there’s no quantity here. He said we don’t quantify it. I asked him why, and he said because you can’t overdose on THC. Which was the theory or the idea six years ago,” Flaspohler said. “This year, there’s been some death certificates signed out by physicians or forensic pathologists that list THC as an overdose now, instead of natural causes.”
 
Other coroners KOMU 8 News spoke with, including Harlow, were incredulous at the idea THC killed Jayke.
 
“I have never seen a case where someone died from an overdose of marijuana. It’s not to say that it hasn’t happened. But I have never seen that in my years of being coroner,” Harlow said.

The DEA stated it has zero reports of overdose from marijuana.
 
Why was the report so inaccurate?  
 
When KOMU 8 News initially spoke with Flaspohler over the phone and asked about the discrepancies in the initial coroner’s report, he admitted the report had errors beyond the name: that many of the inconsistencies, like the location of Jayke’s body, happened because he had deleted pieces of the old report from another death and entered new information but forgot some elements.
 
“He was in the bedroom and that one said he was in the living room,” Flaspohler said over the phone. “That’s because I start with one of those reports and go down there and change and make it fit the situation. My pictures even show where he was at.”
 
Flaspohler said the inaccuracies in the report can be attributed to using old reports as a guide when he starts a new case.
 
“When I’m at the scene, first thing I do, I write out all my stuff. So, I have it handwritten. Then when everything is done, and this is after all the autopsies, if they’re done, or blood work is done, then eventually I will sit down and put it into the computer,” Flaspohler said. “I don’t have a computer program. It’s one we fixed up in Word that simply has a coroner’s thing and a form to put it in. And what I do is I made one, it worked, so the next time when I did a report, I just go in there and type over everything. And it also helps keep me, as far as the consistency. I don’t know why I didn’t finish it, but went back, and the report wasn’t correct.”
 
He also told KOMU 8 News in that phone conversation he had a corrected report, a report no one else in this story had ever seen.
 
A new report and the other man: Inconsistencies remain
 
With that new information, KOMU 8 News requested a copy of the new corrected report – as well as the report for the other man whose name appeared on the top of Jayke’s report. It could point to when Jayke’s report was really written and whether there were similarities that could prove the report had swapped language.
 
Flaspohler gave the new report to KOMU 8 News at the in-person interview, one week after he mentioned the corrected report on the phone. What we found – the other man died in November 2014, five months after the date of Flaspohler’s addendum to Jayke’s record. That meant Jayke’s report was not actually typed up as dated on the form.
 
The new report is signifantly longer and more detailed than the initial report. But it still contains inconsistencies when compared with the initial police report, including the temperature of Jayke’s body. It still states “victim is warm,” when the police noted he was “cool to the touch.” The report for the man whose name was initially on Jayke’s report does not have details that would be similar to Minor’s and explain leftover information from an old report; for example, the man died at work, not in a living room.
 
KOMU 8 News asked Flaspohler how he could be confident in the accuracy of his reports if he did not type them out for years after being at the scene and only relied on his handwritten notes.
 
“Because my official report says almost exactly what my handwritten notes say,” Flaspohler said. “There wasn’t anything additional in there, other than the lab work.”

Since no one had seen the new report obtained only recently by the station, KOMU 8 News asked if he had produced the new copy since the phone call. He said he made the new report shortly after he met with Smith at the State Fair gates in 2016.

Why wasn’t there an autopsy?
 
Flaspohler said, in his more than 20 years as coroner and estimated 1,000 coroner calls, Jayke case was the first he’d marked as “pending investigation” on his initial ruling (a detail only added to the most recent report). Even though he was waiting for results and there were no physical marks on Jayke’s body, Flaspohler decided not to do an autopsy. Jayke’s history of drug use heavily affected that decision.
 
“Talked to the two policemen on scene. They said nope, there’s nothing suspicious. There was some history there,” Flaspohler said.
 
But again, the police report also stated officers were “unable to find any evidence of drug use or of a struggle.”
 
Minor said, “All of these things point to the fact that he should have done an autopsy. If he was sick for three days, we need to know why. Did he get sick from something in the community? Maybe everybody’s at risk. But we’ll never know that.”
 
Flaspohler still said he made his decision not to autopsy because he did not see anything that indicated anything criminal.
 
“It’s a balance between spending the taxpayer’s money as frugally as you can, but still covering the things you need. So, six years ago, it was pretty… well, there were a couple of exceptions. It had to be criminal in order for me to authorize the autopsy and have the county pay for it,” Flaspohler said.
 
He said if he autopsied everyone who died in the county, paying the approximately $1,700 bill on each, he’d run the county up close to $200,000 a year. According to records obtained by Jay Minor’s girlfriend, Debby Ferguson, Flaspohler has returned money from his autopsy and inquest budget to the county nearly every year.

“Frank seems to think that he should not be spending money on autopsies,” Harlow said. “And if that is a coroner’s mindset, that they should not be spending money on autopsies, then they’re probably not doing a very good job of being coroner, because that’s what we do.”
 
Flaspohler said the county’s commissioners are receptive to him and would help him pay for more autopsies if needed; however, he said, he’s still trying to strike a balance in being responsible. His budget has increased from $2,000 in 2007 to more than $5,000 in 2017.
 
‘We have zero authority over the coroner’
 
Minor and Ferguson have been on a mission to tell people in power what happened in Jayke’s case, going to everyone from lawmakers to those in the field of death investigation. Their stop at the coroners’ association meeting in summer 2017 was one of those steps, but they found they couldn’t get much help there.
 
“Unfortunately, there are more cases like this out there,” said Kathleen Little, of the Missouri Coroners’ and Medical Examiners’ Association. “As executive director, it’s very frustrating to look at a family member or tell them over the phone, I’m sorry, there’s nothing I can do. We can look into it. But we have zero authority over the coroner.”
 
Little, who served as coroner for ten years in Clinton County just north of Kansas City, said she is “very frustrated” with the coroner system and laws about death investigations in the state.
 
“Missouri’s laws are very behind,” she said. “Truly, there are no regulations for when a coroner is doing their job or not doing their job.”
 
In Missouri, anyone can run for coroner who is over 21-years-old, a one-year resident of Missouri and a six-month resident of his or her county. No prior medical knowledge or death investigation training is needed.
 
Once elected, the coroner is supposed to attend 20 hours of training per year, but Little said not everyone is attending. While a county is supposed to fine a coroner $1,000 if he or she doesn’t attend, Little said that doesn’t always happen.
 
“There’s no real requirement for them to even come to training. There’s no punishment involved, and it’s up to the county commission to decide whether they’re going to punish the coroner for not attending training,” she said.
 
‘It took way too long’
 
When it comes to the Minor investigation, Flaspohler said it has made him think about changes.
 
“I will tell you it took way too long. I totally agree with that,” Flaspohler said. “I’ve had 1,000 calls, never had one that took this long.”
 
He said he is now tracking his cases using a new computer system and is making sure records are done faster. He said does attend training, including additional, optional training, and he is in favor of upping the training requirements for coroners across the state.
 
He also said a recent coroner’s inquest related to a teen’s suicide death related to bullying has made him look at things differently.
 
“I’ve actually spent the last year dealing with this inquest and saying we need to look at the schools and say we can do better. So, I can look at me and say, I can do better. We can find a better way. We can get more training. We can get a better computer program,” Flaspohler said.
 
‘It’s not about him anymore. It’s about getting change.’
 
While this case has frustrated Minor for the last six and a half years, he and Ferguson are using it to try to push the state of Missouri to make changes. They have called the governor’s and attorney general’s offices, gone to the county commission, the coroner’s board and now lawmakers.

In Missouri, the decision on whether to autopsy and to determine the cause and manner of death are completely in the hands of coroners. The only exception currently is that children under a year old must be autopsied when they die. Coroners say that’s because they are looking for evidence of Sudden Infant Death Syndrome. Other than that, a coroner, who may or may not have training, is making decisions that can impact criminal cases, disease statistics, life insurance payouts, or, at the very least, a family’s sense of closure. 
 
“Some of the rules the coroners are supposed to follow are so broad that they can do these things, but if they don’t, nobody can hold them accountable. As long as that’s the way it is, this will continue,” Minor said.

Ferguson recently started a letter-writing campaign, sending a letter with all of the documents they have to every coroner, medical examiner and lawmaker in the state.
 
“It’s not about him anymore. It’s about getting change, Ferguson said, “It’s not really going to be up to us what happens to Frank. It’s up to the voters and just making sure it doesn’t happen to everybody else. The only way we can do that is to get a law passed. We want a bill that says not what a coroner should do, is what they must do.”
 
Legislature considers bill that would fund expanded training
 
Little, as executive director, is pushing for changes to be made, including the addition of guidelines for when certain tests should be done.
 
“There really needs to be a standard guideline for coroners to follow to tell them this is when you should be doing autopsies and this is when you should be ordering toxicology. And you know, they should be doing their job, which is figuring out the cause and manner of death,” she said.
 
Since meeting Minor and Ferguson, Harlow has been fighting to use their story to create change. He is set to testify in a scheduled hearing Tuesday evening for a bill that would attach a fee to death certificates that would fund training for coroners in the state. It would also make it illegal for coroners who do not attend training to sign death certificates.
 
“For me it has nothing to do with Frank. It has to do with the office of coroner. And it happens to be that, in this particular case, Frank is the coroner, and he holds that office. But the job was not done. And we have to have standard operating procedure for all coroners so that this doesn’t happen, and continue to happen, in the state,” Harlow said.
 
The training is the first step. Harlow, Little, Minor and Ferguson want to see more standards in the laws to ensure no other family has to go without knowing exactly how their loved one died.
 
“We have hit one brick wall after the other, but bricks can come down,” Ferguson said.” You just have to be willing to do the work. Hopefully people will step up and help us now.”
 
Other states: Where does Missouri stack up?

There are other states with similar issues; families in Colorado are raising concerns over similar situations. In some states, the coroner is a de facto position that’s bundled with another office; for example, in small towns in Georgia, the mayor is the coroner.

According to a 2015 report by the CDC, Missouri is one of around 25 states that operate with some version of a county coroner system, though the requirements are lower in this state than some others. For example, in Kansas, coroners must be licensed medical doctors and are appointed, rather than elected.

Some states with citizen county-based coroner systems require coroners to get some type of specialized training once in office; in Minnesota, for example, coroners must become death investigator certified within a few years of taking office. Little said that is one option Missouri might consider examining to help increase training while maintaining the benefits of local control.



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